Some Causes of Eye Pain

From: Marck Manual

Some Causes of Eye Pain

Cause
Suggestive Findings*
Diagnostic Approach

Disorders affecting primarily the cornea†

Contact lens keratitis
Ocular ache, grittiness, prolonged wearing of contact lenses, bilateral red eyes, lacrimation, corneal edema
Clinical evaluation

Corneal abrasion or foreign body
Usually clear history of injury, unilateral pain when blinking, foreign body sensation, Sometimes a predisposing disorder such as trichiasis
Lesion or foreign body visible on slit-lamp examination
Clinical evaluation, including eyelid eversion

Corneal ulcer
Aching, foreign body sensation, photophobia, red eye, grayish opacity on cornea—later a visible crater, Possibly history of sleeping with contact lenses
Scrapings for culture (done by ophthalmologist)

Epidemic keratoconjunctivitis (adenoviral keratitis) when severe
Ocular ache, grittiness, bilateral red eyes, often eyelid edema, copious watery discharge, preauricular lymphadenopathy, chemosis (bulging of the conjunctiva) Occasionally, severe temporary loss of vision
Punctate staining on fluorescein examination
Clinical evaluation

Herpes zoster ophthalmicus
Early: Unilateral vesicles and crusts on an erythematous base in a V1 distribution sometimes affecting the tip of the nose, Eyelid edema, red eye
Late: Redness, quite severe pain Often associated with uveitis
Clinical evaluation, Viral culture if diagnosis is unclear

Herpes simplex keratitis
Acute: Onset after conjunctivitis, blisters on eyelid
Late acute or recurrent: Classic dendritic corneal lesion on slit-lamp examination
Unilateral
Clinical evaluation, Viral culture if diagnosis is unclear

Welder's or UV keratitis
Onset hours after exposure to excessive UV light (eg, from welding or bright sun on snow)
Bilateral, ocular ache, grittiness, Marked injection and typical punctate staining on fluorescein examination of the cornea
Clinical evaluation

Other ocular disorders

Acute angle-closure glaucoma
Severe ocular ache, headache, nausea, vomiting, halos around lights, hazy cornea (caused by edema), marked erythema Intraocular pressure usually > 40
Gonioscopy by ophthalmologist

Anterior uveitis
Ocular ache, ciliary flush, photophobia, often a risk factor (eg, autoimmune disorder, posttrauma)Cells and flare on slit-lamp examination Rarely, hypopyon
Clinical evaluation

Endophthalmitis
Ocular ache, intense conjunctival hyperemia, photophobia, severely decreased visual acuity, risk factors (usually after intraocular surgery or trauma)Unilateral
Cells and flare and commonly hypopyon on slit-lamp examination
Clinical evaluation and cultures of aqueous or vitreous humor by ophthalmologist

Optic neuritis
Mild pain, may worsen with eye movement
Vision loss, from small scotoma to blindness
Afferent pupillary defect (a particularly characteristic finding if patients have some preservation of visual acuity)

Eyelids and cornea normal, sometimes a swollen optic disk
Gadolinium-enhanced MRI considered to look for optic nerve edema and demyelinating lesions within the brain (most commonly due to multiple sclerosis)

Orbital cellulitis
Ocular ache, periocular ache, red and swollen eyelids, proptosis, impaired extraocular movements, decreased visual acuity, fever Unilateral
CT or MRI

Orbital pseudotumor
Ocular ache, periocular ache (may be very severe), unilateral proptosis
Impaired extraocular movements, periorbital edema, gradual onset
CT or MRI Biopsy

Scleritis
Pain very severe (often described as boring), photophobia, lacrimation, red or violaceous patches under bulbar conjunctiva, scleral edema, often history of autoimmune disorder
Clinical evaluation

Disorders causing referred pain

Cluster or migraine headaches
Prior episodes, characteristic temporal pattern (eg, clusters of episodes at the same time each day)
Aura, knife-like quality, throbbing, rhinorrhea, lacrimation, facial flushing, sometimes photosensitivity or photophobia
Clinical evaluation

Sinusitis
Sometimes periorbital edema but eye examination otherwise unremarkable
Purulent rhinorrhea, headache, or eye or facial pain that varies with head position
Facial tenderness, fever, sometimes productive nocturnal cough, halitosis
Sometimes CT

*Routine evaluation should include slit-lamp examination with fluorescein staining and ocular tonometry.

†Most patients have lacrimation and true photophobia (shining a light into the unaffected eye causes pain in the affected eye when the affected eye is shut).

UV = ultraviolet.